Speaker Commitment Form Please fill out your information below and hit submit. All items marked with an asterisk * are required. This information will appear on the event website and in the program book. Name* First Last Suffix Job Title* Email Address*This will not be published online. It's for internal use only. Cell Phone*This will not be published online. It's for internal use only.Proposed Lecture TopicsWe are asking that you present two lecture topics at this year’s conference. Please list below the two proposed topics/titles to be presented to Dr. John for review.Presentation Title 1* Summary of your topic*Please provide a brief 1-3 sentence summary of your suggested topic.Presentation Title 2* Summary of your topic*Please provide a brief 1-3 sentence summary of your suggested topic.Do you have any scheduling conflicts or restrictions during the conference?*The conference will begin Monday, July 18 and end on Thursday, July 21. Lectures will take place from 8:00 AM to 1:30 PM. If there is a specific day or time you have a conflict with, please enter it in the box below. Travel arrangements to and from Sarasota will be set at a later date.YesNoSchedule Conflicts*Please enter your schedule conflicts/request below.Conflict of Interest DisclosureThe Lake Erie College of Osteopathic Medicine (LECOM) must disclose to the program audience any real or apparent conflict(s) of interest of faculty related to the content of their presentation(s). Having an interest or an affiliation with a corporate organization does not prevent a speaker from making a presentation, but the relationship must be made known in advance to the audience in accordance with the Standards of the Accreditation Council for Continuing Medical Education.Do you have any financial information to disclose?*YesNoDisclosure Statement*With respect to my presentation, I do not have any financial arrangement or affiliations with any corporate organization(s) offering financial grants or support or development or sales of products to be discussed in this CME Program. I have no disclosuresDisclosure Statement*I do have a financial interest/arrangement or affiliation with one or more corporate organizations offering financial grants or support or development or marketing of products to be discussed in this CME program. I have conflicts to disclose and they are listed below.Name of Corporate Organization(s) Grant/Research Support Consultant Speakers Bureau Major Shareholder Other Financial or Material Interest Guidelines for Presenters*All presenters are asked to adhere to the following guidelines: • This conference will be an in-person, live event while also live-streamed to attendees using Zoom. • Presenters, please arrive 30 minutes prior to your scheduled lecture. • A member from the communications and marketing department will meet all presenters at the registration desk outside of the lecture space. • PowerPoint files must be sent to firstname.lastname@example.org by June 30. • All presentations should be formatted in the 16:9 format and not the 4:3 format. • Please notify me ahead of time if there are any video or audio clips that will be included in your presentation. • We will make all speaker presentations and videos available to all conference attendees and all speakers. • Videos and lecture material will be located on https://cme.lecom.edu and available only to registered attendees. In order to offer this, we will video/audio record all speaker presentations. • Access to the recorded lectures will be provided two weeks after the conference ends. • All presenters are asked to arrive in business casual attire. By checking this box, you agree to speak at this event and you agree to the guidelines listed.CommentsThis field is for validation purposes and should be left unchanged.